Provider Demographics
NPI:1609592237
Name:JENSEN, BETHANY (PTA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 STARLING DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-3533
Mailing Address - Country:US
Mailing Address - Phone:317-625-1638
Mailing Address - Fax:
Practice Address - Street 1:1540 STARLING DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3533
Practice Address - Country:US
Practice Address - Phone:317-625-1638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021027464225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant